Download Endocrinology

OBJECTIVES FOR COMMON CLINICAL PROBLEMS
Diabetes
A. KNOWLEDGE: Students should be able to define, describe, and discuss:
1. Diagnostic criteria for impaired fasting glucose and impaired glucose
tolerance
2. Diagnostic criteria for type I and type II diabetes mellitus, based on a history,
physical examination, and laboratory testing
3. Pathophysiology, risk factors, and epidemiology of type I and type II diabetes
mellitus
4. The basic principles of the role of genetics in diabetes mellitus
5. Presenting symptoms and signs of type I and type II diabetes mellitus
6. Presenting symptoms and signs of diabetic ketoacidosis (DKA) and
nonketotic hyperglycemic (NKH)
7. Pathophysiology for the abnormal laboratory values in DKA and NKH
including plasma sodium, potassium, and bicarbonate
8. Precipitants of DKA and NKH
9. Major causes of morbidity and mortality in diabetes mellitus (coronary artery
disease, peripheral vascular disease, hypoglycemia, DKA, NKH coma,
retinopathy, neuropathy—peripheral and autonomic, nephropathy, foot
disorders, infections)
10. Laboratory tests needed to screen, diagnose, and follow diabetic patients
including: glucose, electrolytes, urea, creatinine, fasting lipid profile, HgA1c,
urine microalbumin/creatinine ratio, urine dipstick for protein
11. Non-pharmacologic and pharmacologic (drugs (oral agents and insulins) and
side effects) treatment of diabetes mellitus to maintain acceptable levels of
glycemic control, prevent target organ disease, and other associated
complications
12. The specific components of the Canadian Diabetes Association (CDA) dietary
recommendations for type I and type II diabetes mellitus
13. Basic management of diabetic ketoacidosis and nonketotic hyperglycemic
states, including the similarities and differences in fluid and electrolyte
replacement
14. Basic management of blood glucoses in the hospitalized patient
15. The Somogyi effect and the Dawn phenomenon and the implications of each
in diabetes pharmacologic management
16. The fundamental aspects of the Canadian Diabetes Association (CDA)
clinical practice recommendations and how they encourage high quality
diabetes care
17. Awareness of target levels and basic management of hypertension and
hyperlipidemia in the diabetic patient
B. SKILLS: Students should be able to demonstrate specific skills including:
1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
• Weight changes
• Hypo- or hyperglycemic symptoms
• Medication history (adherence, side effects, other medications)
• Home glucose monitoring results
• Target organ disease complications (cardiovascular, foot,
gastrointestinal, infectious, neurological, sexual, skin, urinary, or vision
symptoms)
• Diet history (total caloric intake, intake of sugar-containing foods,
intake of saturated fat and cholesterol, physical activity level, timing of
meals)
• Screen for depression
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
• Skin examination for diabetic dermopathy, furuncles/carbuncles,
candidiasis, necrobiosis lipoidica diabeticorum, dermatophytosis, and
acanthosis nigricans
• Fundoscopic exam
• Arterial pulses
• Peripheral nerves (e.g. monofilament testing)
• Examination of the feet for corns, calluses, and ulcerations
• In patients with DKA or NKH evaluate for mental status alterations,
Kussmaul’s respirations, fruity breath, and signs of volume depletion
3. Differential diagnosis: Students should be able to generate a differential
diagnosis recognizing specific history and physical exam findings that suggest
a specific etiology for:
• Hyperglycemia
• Hypoglycemia
• Anion gap acidosis
• Ketosis
• Hyperosmolality
4. Laboratory interpretation: Order and interpret diagnostic and laboratory tests
based on the differential diagnosis. These may include:
• Fasting serum GLC
• Electrolytes, Urea, Cr
• Serum and urine ketones
• Serum and urine osmolality
• HbA1c
• Fasting lipid profile
• UA
• Urine microalbumin/creatinine ratio
• 24-hour urine for protein and creatinine clearance
5. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
• Writing appropriate fluid and insulin orders and outline critical steps for
the treatment of DKA and DKH
• Counseling patients regarding basic features of CDA diabetic diet
recommendations
• Instructing patients in home blood glucose monitoring
• Counseling patients on behavior changes (smoking cessation,
medication adherence, poor glycemic control, obesity, hypertension,
dyslipidemia, and infection) to avoid the complications of diabetes
• Counseling patients regarding basic foot care
• Determining when to institute diet therapy, oral hypoglycemic agents,
and insulin therapy
• Calculating an appropriate insulin dose for a diabetic patient
• Using community resources (CDA, hospital and community-based
education programs) to aid the patient in understanding and managing
his or her illness
• Determining when to obtain consultation from an endocrinologist,
nephrologist, ophthalmologist, podiatrist, and dietician
• Determining when to obtain consultation from a social worker
• Determining when to obtain consultation from a psychologist
Approved by Department of Medicine Undergraduate Medical Education Committee
September 4, 2009